Justia Insurance Law Opinion Summaries

A provider of air ambulance services transported a patient insured by a health maintenance organization, but the provider was not part of the insurer’s network. After the transport, the provider and insurer could not agree on the payment amount. The dispute was submitted to the Independent Dispute Resolution (IDR) process established by the federal No Surprises Act, which requires each party to submit a payment offer and supporting rationale to an arbitrator. The arbitrator, a certified IDR entity, selected the insurer’s lower payment offer. The provider alleged that the insurer had misrepresented its “Qualifying Payment Amount” (QPA) by submitting a lower QPA to the arbitrator than it had previously provided to the provider, and claimed this constituted fraud.The United States District Court for the Middle District of Florida dismissed the provider’s complaint, finding that judicial review of IDR awards is limited to the grounds set forth in the Federal Arbitration Act (FAA), and that the provider’s allegations did not meet the heightened pleading requirements for fraud. The court also dismissed the arbitrator from the case with prejudice, holding that the No Surprises Act does not create a cause of action against IDR entities.On appeal, the United States Court of Appeals for the Eleventh Circuit affirmed the district court’s dismissal. The Eleventh Circuit held that the No Surprises Act incorporates the FAA’s limited grounds for vacating arbitration awards and that the provider failed to adequately plead fraud or undue means under those standards. The court also found that the arbitrator did not exceed its authority and that it was not necessary to name the arbitrator as a defendant to challenge the award. The judgment of the district court was affirmed in full. View "REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc." on Justia Law

A resident of Madison County, Mississippi, received medical treatment at a hospital in Hinds County and later filed a claim with her health insurer, a foreign corporation doing business in the state. The insurer partially paid the claim but later, through its third-party administrator, asserted the hospital was out of network before eventually admitting it was in network. Despite repeated efforts by the insured to resolve the dispute, the insurer failed to pay the remaining balance or provide an explanation, ultimately stating the claim was untimely. The insured then sued the insurer and the administrator in Hinds County, seeking damages for breach of contract and related claims.The Circuit Court of Hinds County denied the insurer’s motion to dismiss or transfer venue to Madison County. Only the insurer sought and was granted an interlocutory appeal from this order. The administrator did not join the appeal.The Supreme Court of Mississippi reviewed the case, applying de novo review to the interpretation of the venue statute and abuse of discretion to the trial court’s venue ruling. The Court held that, under Mississippi Code Section 11-11-3(1)(a)(i), venue is proper where a substantial act or omission by the defendant caused the injury for which the plaintiff seeks redress. The Court found that the medical treatment in Hinds County was not a substantial event caused by the insurer that resulted in the alleged injury; rather, the alleged injury arose from the insurer’s acts or omissions related to the insurance contract, which were not tied to Hinds County. The Court overruled prior precedent to the extent it conflicted with this interpretation and concluded that venue was proper in Madison County. The judgment of the Hinds County Circuit Court was reversed and the case remanded for further proceedings in Madison County. View "National Health Insurance Company v. Lever" on Justia Law

Lauren Woods was injured in a car accident involving an underinsured motorist and sought benefits from her insurer, Progressive American Insurance Company, under her policy’s underinsured motorist provision. Progressive declined to pay the full policy limit. Woods then sued Progressive for breach of contract and statutory bad faith under Florida law, alleging that Progressive failed to settle her claim in good faith. After serving civil remedy notices, Woods’s case was removed to federal court based on diversity jurisdiction.The United States District Court for the Southern District of Florida first held a jury trial on Woods’s underinsured motorist claim, resulting in a verdict and final judgment in her favor that exceeded the policy limit. Woods then proceeded with her statutory bad faith claim before the same court. Prior to the bad faith trial, the parties stipulated to certain facts, including the existence and amount of the prior verdict and judgment. They also agreed that the magistrate judge would determine damages, and the jury would decide only liability. At the start of the bad faith trial, Woods limited her theory to Progressive’s conduct before the underinsured motorist trial, and the court excluded evidence and instructions regarding the prior verdict and excess judgment. The jury found for Progressive on the bad faith claim, and the court denied Woods’s motion for a new trial.On appeal, the United States Court of Appeals for the Eleventh Circuit held that the district court did not abuse its discretion in excluding the prior verdict and excess judgment from the bad faith trial. The court found that, given Woods’s stipulation limiting the scope of her claim and the parties’ agreement that damages would be determined by the judge, the excluded evidence was irrelevant to the jury’s determination of liability. The Eleventh Circuit affirmed the district court’s judgment in favor of Progressive. View "Woods v. Progressive American Insurance Company" on Justia Law

Bliv, Inc. owned a commercial building insured by Charter Oak Fire Insurance Company against hail damage, but not against damage caused by wear and tear. After a storm on July 9, 2021, Bliv claimed that water intrusion had damaged both the exterior and interior of the building, asserting that hail was the cause. Charter Oak’s expert, Isaac Gaetz, inspected the property and found hail damage to vents and air conditioner fins, but no damage to the roof’s membrane. Gaetz concluded that the water intrusion was due to long-term wear and tear, not hail. Bliv disputed this and retained its own expert, Brian Johnson, who opined that hail caused the loss, relying on reports and satellite images rather than direct testing or inspection of the interior.The United States District Court for the Eastern District of Missouri reviewed the case. Charter Oak moved to exclude Johnson’s expert opinion, arguing it lacked sufficient factual support and was not based on reliable methods. The district court found Johnson qualified but excluded his opinion due to deficiencies in his investigation, such as failing to review key reports, not inspecting the interior, and not conducting independent testing. Without Johnson’s opinion, Bliv could not rebut Charter Oak’s causation evidence, and the district court granted summary judgment in favor of Charter Oak.On appeal, the United States Court of Appeals for the Eighth Circuit reviewed the district court’s exclusion of Johnson’s opinion under the abuse of discretion standard. The appellate court found that, despite some inconsistencies in the district court’s reasoning, there was a sufficient basis for exclusion because Johnson’s opinion relied on incomplete information and failed to address critical evidence. The Eighth Circuit held that the district court did not abuse its discretion and affirmed the summary judgment in favor of Charter Oak. View "Bliv, Inc. v. The Charter Oak Fire Insurance Company" on Justia Law

A mass shooting occurred at a Florida high school in 2018, resulting in numerous deaths and injuries. The Sheriff’s Office, which employed a school resource officer at the school, faced 60 lawsuits from victims alleging negligence in failing to secure the premises. The Sheriff’s Office held an excess liability insurance policy with Evanston Insurance Company, which required the Sheriff to pay a $500,000 self-insured retention (SIR) per “occurrence” and a $500,000 annual aggregate deductible before coverage would be triggered. The central dispute was whether the shooting constituted a single “occurrence” under the policy, or multiple occurrences—one for each victim or gunshot.The United States District Court for the Southern District of Florida reviewed the case after the Sheriff filed a declaratory judgment action. The district court denied Evanston’s motion to dismiss, finding that the policy’s definition of “occurrence” was ambiguous under Florida law, and that ambiguity should be construed in favor of the insured. The court determined that the Parkland shooting was a single occurrence, meaning only one SIR applied. The court also found that the Sheriff had satisfied both the SIR and the deductible through legal expenses and other covered claims, and awarded attorney’s fees and costs to the Sheriff.The United States Court of Appeals for the Eleventh Circuit affirmed the district court’s rulings. The Eleventh Circuit held that a justiciable controversy existed, as the Sheriff had demonstrated a substantial likelihood of future injury and had satisfied the policy’s prerequisites for coverage. The court further held that, under controlling Florida law, the term “occurrence” was ambiguous and must be construed in favor of the insured, resulting in the Parkland shooting being treated as a single occurrence. The court also upheld the award of attorney’s fees and costs to the Sheriff. View "Sheriff of Broward County v. Evanston Insurance Company" on Justia Law

D S Avionics Unlimited LLC owned a 1964 Piper PA-30 aircraft, which was insured under a policy issued by U.S. Specialty Insurance Company for the period between June 27, 2014, and June 27, 2015. In November 2014, DSA delivered the aircraft to a mechanic for maintenance at an Omaha airport. After a dispute between the mechanic and the airport owner, the mechanic was locked out of the hangar, and the aircraft was moved outside. When DSA attempted to retrieve the aircraft, a truck blocked its removal, and the airport owner refused to move it until storage fees were paid. The aircraft subsequently disappeared from view, and the airport owner informed authorities and the insurer that he was holding the aircraft pending payment. DSA reported the aircraft stolen and submitted a claim to USSIC, which was denied.USSIC filed suit in the District Court for Douglas County, Nebraska, seeking a declaration of noncoverage. DSA counterclaimed for breach of contract and bad faith. Both parties moved for summary judgment. The district court ruled in favor of USSIC, finding that DSA’s claim was not covered because there was no “accident” under the policy and that the Conversion Exclusion applied. The court also found that DSA failed to prove damages and that USSIC had an arguable basis for denial. DSA appealed, and the matter was moved to the Nebraska Supreme Court’s docket.The Nebraska Supreme Court held that DSA’s claim was within the policy’s coverage for “direct physical loss” caused by an “accident,” as defined by the policy. The court found that the airport owner’s actions constituted an “accident” from DSA’s perspective and that the Conversion Exclusion did not apply, as conceded by USSIC. The Supreme Court reversed the district court’s order and remanded for further proceedings regarding USSIC’s alleged bad faith and any damages due to DSA. View "U.S. Specialty Ins. Co. v. D S Avionics" on Justia Law

In April 2018, Mark Fiechtner was involved in a motor vehicle accident in Lincoln County, South Dakota, caused by another driver, Caitlyn Belliveau, who lost control on icy roads. Fiechtner subsequently experienced neck pain, headaches, vision problems, and memory issues, seeking treatment from various healthcare providers. He held an insurance policy with American West Insurance Company, which paid the $10,000 medical benefits limit. Fiechtner also received the $100,000 liability limit from Belliveau’s insurer. He then sought $900,000 in underinsured motorist (UIM) benefits from American West, but was offered only $10,000. After unsuccessful negotiations, Fiechtner sued American West for breach of contract, bad faith, punitive damages, and attorney fees.The case was tried in the Circuit Court of the Second Judicial Circuit, Lincoln County, South Dakota. At trial, evidence showed that American West’s investigation of the UIM claim was limited and did not include contacting Fiechtner or his healthcare providers, nor reviewing prior claim notes. The jury found in favor of Fiechtner on all counts, awarding $400,000 for breach of contract, $250,000 for bad faith, $890,000 in punitive damages, and attorney fees. The circuit court denied American West’s post-trial motions for judgment as a matter of law and for a new trial.The Supreme Court of the State of South Dakota reviewed the case. It affirmed the circuit court’s denial of American West’s motions, holding that sufficient evidence supported the jury’s findings of bad faith and punitive damages, and that the circuit court did not clearly err in awarding attorney fees under SDCL 58-12-3. The Supreme Court also found no abuse of discretion in the circuit court’s evidentiary rulings. View "Fiechtner v. American West Ins." on Justia Law

A medical-malpractice insurance company based in California issued a policy to a healthcare provider headquartered in Ohio. After a patient sued the provider in Connecticut, the provider submitted the claim to its insurer, which accepted coverage and managed the defense. Disagreements arose between the provider and insurer regarding settlement strategy, leading the provider to self-fund a settlement to avoid the risk of a verdict exceeding policy limits. Subsequently, the provider sued the insurer in Ohio, alleging bad-faith insurance-claim handling and seeking reimbursement for the settlement and related costs.The insurer moved to stay proceedings and compel arbitration under the policy’s arbitration clause, which had been amended to require arbitration of “any dispute…relating to this Policy (including any disputes regarding [the insurer’s] contractual obligations).” The Stark County Court of Common Pleas granted the motion to compel arbitration. On appeal, the Fifth District Court of Appeals reversed, relying on the Ohio Supreme Court’s decision in Scott Fetzer Co. v. American Home Assurance Co., Inc., and held that the bad-faith claim was a tort arising by operation of law and thus not subject to arbitration under the policy’s endorsement.The Supreme Court of Ohio reviewed the case and held that the arbitration agreement in the insurance policy is a broad clause, creating a presumption of arbitrability. The Court found that the presumption was not overcome, as the bad-faith claim could not be maintained without reference to the policy or the insurer-insured relationship, and there was no express exclusion of such claims from arbitration. The Supreme Court of Ohio reversed the Fifth District’s judgment and reinstated the trial court’s order compelling arbitration. View "U.S. Acute Care Solutions, L.L.C. v. Doctors Co. Risk Retention Group Ins. Co." on Justia Law

An attorney with over two decades of experience brought suit against an insurance company and its agent after his life insurance policy lapsed due to a missed payment. He claimed to have cured the lapse by paying the overdue premium and submitting required information, and alleged that the insurer confirmed reinstatement before later refunding his payment and rescinding the reinstatement. The insurer denied ever reinstating the policy and asserted it had expired by its own terms. The attorney filed suit in state court, alleging breach of contract and other claims. After removal to federal court, the parties mediated and signed a settlement memorandum outlining five essential terms, including a $10,000 payment to the plaintiff and mutual releases. The memorandum stated that final settlement language would use standard contractual terms.After mediation, the plaintiff refused to sign the draft settlement agreement, objecting to a non-reliance clause he claimed was not discussed during mediation. He also began raising new questions about the status of his insurance policy. He moved to vacate the settlement and sought further discovery, while the defendants moved to enforce the settlement. The United States District Court for the Western District of Missouri held an evidentiary hearing, which the plaintiff missed, and then granted the defendants’ motion to enforce the settlement and denied the plaintiff’s motions. The plaintiff’s motion for rehearing was also denied.On appeal, the United States Court of Appeals for the Eighth Circuit held that the settlement memorandum contained all essential terms and that the non-reliance clause in the draft agreement was standard language, not a material new term. The court found no clear error in the district court’s factual findings and no abuse of discretion in denying a new hearing. The Eighth Circuit affirmed the district court’s judgment enforcing the settlement. View "Schlecht v. Goldman" on Justia Law

Nearly a million barrels of crude oil owned by a U.S. company were seized from a vessel in Venezuelan waters by Venezuelan authorities under threat of force. The oil was insured under a marine cargo reinsurance policy that covered losses arising from war-related risks, including “insurrection.” The insured company claimed that the political turmoil in Venezuela, including the contested presidency and violent suppression of opposition, constituted an insurrection as defined by the policy. The reinsurers denied coverage, arguing that the events did not meet the policy’s definition of insurrection, leading to litigation.The United States District Court for the Southern District of New York reviewed cross-motions for summary judgment. The court found the term “insurrection” in the policy to be ambiguous and, applying New York law and the doctrine of contra proferentem, construed the ambiguity in favor of the insured. The court held that the Maduro regime’s actions constituted an insurrection within the meaning of the policy. The case proceeded to trial on causation and damages, where the jury found in favor of the insured on most issues, awarding over $54 million in damages plus interest.On appeal, the United States Court of Appeals for the Second Circuit considered challenges to the district court’s summary judgment ruling, judicial notice orders, and jury instructions on causation. The Second Circuit held that the district court did not err or abuse its discretion in any of the challenged rulings. It affirmed that the policy’s “arising from” language required only but-for causation, not proximate causation. The court affirmed the district court’s judgment in all respects, upholding the award to the insured. View "CITGO Petroleum Corp. v. Ascot Underwriting Ltd." on Justia Law